A 45 year old man is found dead in the orthopedic room of an emergency department. He has no signs of trauma and no past medical history.

What do you think happened?

(BUCKLE UP--IT& #39;S A TOX MURDER MYSTERY THREAD)
https://abs.twimg.com/emoji/v2/... draggable="false" alt="💀" title="Schädel" aria-label="Emoji: Schädel">https://abs.twimg.com/emoji/v2/... draggable="false" alt="🩸" title="Tropfen Blut" aria-label="Emoji: Tropfen Blut">https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔪" title="Küchenmesser" aria-label="Emoji: Küchenmesser">https://abs.twimg.com/emoji/v2/... draggable="false" alt="💀" title="Schädel" aria-label="Emoji: Schädel">https://abs.twimg.com/emoji/v2/... draggable="false" alt="🩸" title="Tropfen Blut" aria-label="Emoji: Tropfen Blut">https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔪" title="Küchenmesser" aria-label="Emoji: Küchenmesser">https://abs.twimg.com/emoji/v2/... draggable="false" alt="💀" title="Schädel" aria-label="Emoji: Schädel">

Clue #1: The man was hired by the hospital to clean the drain/pipes that was blocked by plaster being washed down the sink by silly residents. https://abs.twimg.com/emoji/v2/... draggable="false" alt="🙅‍♀️" title="Frau gestikuliert „Nicht OK“" aria-label="Emoji: Frau gestikuliert „Nicht OK“">https://abs.twimg.com/emoji/v2/... draggable="false" alt="🙅‍♀️" title="Frau gestikuliert „Nicht OK“" aria-label="Emoji: Frau gestikuliert „Nicht OK“"> (Stop washing your plaster down the sink! I see you!! STOP DOING IT! It& #39;s nasty and grosshttps://abs.twimg.com/emoji/v2/... draggable="false" alt="🤮" title="Spuckendes Gesicht" aria-label="Emoji: Spuckendes Gesicht">) (2/x)

Clue #2: The material used to make the splints was Plaster of Paris. This product is still used today. Check out this https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌟" title="Leuchtender Stern" aria-label="Emoji: Leuchtender Stern">glowinghttps://abs.twimg.com/emoji/v2/... draggable="false" alt="👌" title="OK-Hand" aria-label="Emoji: OK-Hand">review from Amazon (3/x)

Clue #3: The man was using sulfuric acidhttps://abs.twimg.com/emoji/v2/... draggable="false" alt="🥴" title="Woozy face" aria-label="Emoji: Woozy face">to clean the drain and dissolve the clogged up Plaster of Paris. I& #39;m a toxicology fellow, not a drain declogging expert, what do you want from me? I don& #39;t know why they used that. (4/x)

Clue #4: What happens to Plaster of Paris when its gunked up in the pipes? It gets chewed up by bacteria. Under anaerobic conditions, the bacteria can make a nasty, thick (thicc?) calcium sulfide sludge. Mmmm. I imagine the sludge looks like this: (5/x)

Clue #5: Sulfuric acid + Calcium Sulfide = ??? UGHHHHH https://abs.twimg.com/emoji/v2/... draggable="false" alt="😑" title="Ausdrucksloses Gesicht" aria-label="Emoji: Ausdrucksloses Gesicht">https://abs.twimg.com/emoji/v2/... draggable="false" alt="😑" title="Ausdrucksloses Gesicht" aria-label="Emoji: Ausdrucksloses Gesicht"> chemistry. Yet, the answer is in there. These two combine in the following chemical reaction, giving us our answer. (6/x)

THE CULPRIT: https://abs.twimg.com/emoji/v2/... draggable="false" alt="🚨" title="Polizeiautos mit drehendem Licht" aria-label="Emoji: Polizeiautos mit drehendem Licht">Hydrogen Sulfidehttps://abs.twimg.com/emoji/v2/... draggable="false" alt="🚨" title="Polizeiautos mit drehendem Licht" aria-label="Emoji: Polizeiautos mit drehendem Licht"> gas was formed by the chemical reaction above and it caused the man to die pretty quickly. Perhaps the only thing abnormal on the patient& #39;s skin exam was his silver wedding ring that had tarnished after reacting with the gas. (7/x)

Hydrogen sulfide is a colorless gas that classically smells like rotten eggs https://abs.twimg.com/emoji/v2/... draggable="false" alt="🍳" title="Kochen" aria-label="Emoji: Kochen">. It gets inhaled into the body and interferes with oxidative phosphorylation and causes cellular hypoxia. What does this translate into? Rapid unconsciousness and cardiopulmonary arrest.https://abs.twimg.com/emoji/v2/... draggable="false" alt="👎" title="Daumen runter" aria-label="Emoji: Daumen runter">https://abs.twimg.com/emoji/v2/... draggable="false" alt="👎" title="Daumen runter" aria-label="Emoji: Daumen runter">https://abs.twimg.com/emoji/v2/... draggable="false" alt="👎" title="Daumen runter" aria-label="Emoji: Daumen runter"> (8/x)

Hydrogen sulfide is scary. People will die in groups because whenever someone (not wearing PPE) goes to rescue the victim, they become exposed to the gas and then pass out/die...and the cycle continues.https://abs.twimg.com/emoji/v2/... draggable="false" alt="😶" title="Mundloses Gesicht" aria-label="Emoji: Mundloses Gesicht">https://abs.twimg.com/emoji/v2/... draggable="false" alt="😶" title="Mundloses Gesicht" aria-label="Emoji: Mundloses Gesicht">In fact, at ~1000ppm, breathing will STOP after just 1-2 breaths. (9/x)

TREATMENT: Moving the victim to fresh air and giving oxygen, in addition to good supportive care and respiratory/ventilatory support, is key. Antidotes such as sodium nitrite work by inducing methemoglobinemia which scavenges the hydrogen sulfide. (10/x)

Anyways, I wanted to do a fun little thread on hydrogen sulfide so I hope you all enjoyed. This was based on a real case report found here: https://jamanetwork.com/journals/jama/article-abstract/362672

If">https://jamanetwork.com/journals/... this interests you...the world could always use more toxicologists! https://abs.twimg.com/emoji/v2/... draggable="false" alt="😀" title="Grinsendes Gesicht" aria-label="Emoji: Grinsendes Gesicht">https://abs.twimg.com/emoji/v2/... draggable="false" alt="😀" title="Grinsendes Gesicht" aria-label="Emoji: Grinsendes Gesicht"> (thread complete!)